Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019 - Vision 2020 and Annual Quality Account 2018 ...
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Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Contents
Foreword 1
Section 1: 3
Introduction to our
Quality Strategy and Accounts 2018/19
What is the Quality Strategy?
Section 2: 12
Looking Forward:
Our Quality goals and targets 2018-19
Section 3: 21
Looking Back:
Quality performance 2017-18
Section 4: 28
Statements of assurance from the Board
Section 5: 36
Reporting on core indicators
Section 6: 45
Other services
Section 7: 49
Feedback from our partners and stakeholders
Appendix 1: 52
Clinical Audit : Learning outcomes
Appendix 2: 55
CQUINS 2017-18 and 2018-19 : UPDATE
London Ambulance Service NHS Trust
Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019 Foreword The London Ambulance Service is the only pan London Trust and is the busiest ambulance service in the country responding year on year to increasing demands. Our Trust was inspected February 2016 by the CQC, who gave us an overall rating of ‘requires improvement’ in their final report. The care we give to patients was rated as outstanding, a number of services were rated as ‘good’ but the standards observed were not consistent nor of the quality the Trust aspires to deliver. During the year we have delivered a comprehensive action plan and external assessment confirms what we know, that our services have improved over the last two years. However we also know there is further improvement to make to achieve our vision of providing a world class service. Through this strategy, we want to strive for ‘outstanding’ Care Quality Commission (CQC) rating across our sites and services by 2020. These are undeniably challenging times for healthcare, with NHS services under increased pressure due to our ageing and growing population. However, with these challenges, we have an exciting opportunity when it comes to improving healthcare quality. We hope our commitment to improvement and our determination to get things right for our patients, people and stakeholders is clear in this strategy. We are working to harness opportunities to continuously improve in order to provide safe, high quality, patient-centred care for all our patients. In addition we need to ensure that our staff are provided with the skill and support to deliver the right care and feel motivated and able to do so. To achieve this, we are rolling out a programme of quality improvement and human factors training and developing our systems and processes to build an organisation-wide culture of continuous improvement. At the same time, patients will have a stronger voice than ever before, and we have begun and will continue to work more closely with the people and communities we serve to make sure that the care they receive is centred on their needs. This strategy is the plan by which we will continue our journey to achieve our ambitions and a positive outcome in subsequent CQC inspections as continuous quality improvement becomes our business as usual. Dr Patricia Bain Chief Quality Officer London Ambulance Service NHS Trust 1
Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Statement of Directors responsibilities
The directors are required under the Health Act 2009 and the National
Health Service (Quality Accounts) Regulations to prepare Quality Accounts
for each financial year.
NHSI has issued guidance to NHS trust boards on the form and content of
annual quality accounts (which incorporates the above legal requirements)
and the arrangements that NHS trust boards should put in place to support
the data quality for the preparation of the quality account. The London
Ambulance Service, whilst not a Foundation Trust has prepared the annual
quality account in line with this guidance ensuring directors have taken
steps to satisfy themselves that:
• The content of the Quality Account meets the requirements set out in
the NHS Foundation Trust Annual Reporting Manual 2018/19 and
supporting guidance
• The content of the Quality Account is not inconsistent with internal and
external sources of information including:
– board minutes and papers for the period April 2017 to March 2018
– papers relating to quality reported to the board over the period April
2017 – March 2018
– feedback from commissioners dated April 2018
– feedback from Overview and Scrutiny Committee dated March 2018
– the Trust’s complaints report published under regulation 18 of the
Local Authority Social Services and NHS Complaints Regulations 2009,
dated May 2018
– the 2017 national staff survey
• The quality report presents a balanced picture of the NHS trust’s
performance over the period covered
• The performance information reported in the quality report is reliable
and accurate
• There are proper internal controls over the collection and reporting of
the measures of performance included in the quality report, and these
controls are subject to review to confirm that they are working
effectively in practice
• The data underpinning the measures of performance reported in the
quality report is robust and reliable, conforms to specified data quality
standards and prescribed definitions, is subject to appropriate scrutiny
and review and
The Directors confirm to the best of their knowledge and belief they have
complied with the above requirements in preparing the quality report.
By order of the Board
Chair Date
Chief Executive Date
2 London Ambulance Service NHS Trust
Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019 Section 1: Introduction to our Quality Strategy and Accounts 2018/19 The quality strategy for the Trust, aims to bring together our plans in line with over overarching strategy, business planning process and the CQC quality assessment framework. The purpose of the strategy is to set out the goals and targets for London Ambulance Service (LAS) in providing high-quality services over the next year and, therefore, delivering our vision and objectives. London Ambulance Service NHS Trust 3
Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Developing our Trust-wide The Trust’s vision
strategy The London Ambulance Service is uniquely placed to
play a wider role within the London health economy.
We recently published a document entitled ‘Our
strategic intent 2018/19 – 2022/23’, it sets out our Our ambition is to become a world-class ambulance
ambition and describes how we plan to evolve in order service for a world-class city: London’s primary
to achieve improved outcomes and a better experience integrator of access to urgent and emergency care on
for patients. scene, on phone and online.
It formed the basis for a six-week period of consultation This vision will be delivered through the achievement
that took place with internal and external stakeholders of the Trust’s strategic objectives, which are:
during November and December 2017, the main
purpose of which has been to ensure that we fully • Acting as a multi-channel single point of access and
address the needs of patients, our staff, partner NHS triage to the urgent and emergency care system
organisations and other business partners across across London.
London.
• Providing a high quality and efficient differentiated
We are working with many of our stakeholders and clinical service that better matches care to patient
business partners, including the CQC, to co-design our urgent and emergency needs.
final strategy, which is due for release early 2018. • Using our influence and working with partners to
ensure a consistent approach to urgent and
Our trust strategy focuses on improvement, and emergency care.
therefore supports delivery of our vision and objectives.
It sets out a number of the key enablers and examples Our Purpose
of the projects required to improve performance to
illustrate the breadth of our work programme. We exist to:
These objectives have quality embedded in them. This • Provide outstanding care for all of our PATIENTS
shows the commitment and reality that quality drives • Be a first class employer, valuing and developing the
all that we do. skills, diversity and quality of life of our PEOPLE
• Provide the best possible value for the tax paying
PUBLIC, who pay for what we do
• PARTNER with the wider NHS and public sector to
optimise healthcare and emergency services
provision across London
4 London Ambulance Service NHS Trust
Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019 What is the Quality Strategy? Our quality strategy is the plan through which we focus on the quality of clinical care and to ensure that we continuously improve our services. It ensures that quality drives the overall direction of our work and that the patient is at the centre of everything that we do. London Ambulance Service NHS Trust 5
Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
This strategy sets out our definition they are providing the best service reportable goals to aim for. These
of quality, and describes our vision they can, are valued and are targets will be redefined each year
and direction, ensuring that quality important. We recognise the in our annual quality account, with
is our number one priority. It sets importance of building a culture progress monitored through the
out our five domain quality goals where quality and its continual Trust’s governance system. We
and associated targets and a improvement is our priority and we believe that if we can meet our
number of projects which we must are committed to doing so. We targets under each quality domain,
focus on to ensure we can evidence want a shared pride in the Trust and we will see significantly improved
that our services are safe, effective, assurance that it is the very best it outcomes for our patients and a
caring, well led and responsive. It can be. better working environment for our
also describes the governance people. Our goals and targets have
arrangements to ensure delivery How we developed the strategy been selected to have the highest
and sustainability from 2018/19. The The strategy has been informed by impact across the Trust and are
strategy also outlines our current the reports and recommendations purposely challenging.
position, showing the from key stakeholders, staff and
improvements we have made in our patient representatives and the CQC We recognise in particular that we
2017-18 Quality Account priorities framework. We also assessed our need to improve many of our
and what we are building on going progress against priorities in our last processes and systems to ensure
forward. quality account. better outcomes and experience for
our patients. A series of Trust-wide
It is ambitious, setting out our Comparison was also undertaken of improvement projects, informed by
commitment to make quality trends and variation from a range our CQC inspection action plan and
central to all that we do. It also of intelligence including: a review of the key lines of enquiry
reinforces that wherever possible, that the CQC use, have been
our focus will be on embracing new • Patient surveys established to deliver specific time
ways of working to improve care for bound programmes of work.
• Staff surveys
patients and integrating healthcare
across the wider integrated urgent • Governance data, e.g. incidents, What is our definition of quality?
and emergency care system. complaints, claims and audit We have based our definition of
quality on the CQC’s framework,
This was then merged with
It provides a modern approach to which draws on the Francis, Keogh
feedback from key stakeholders,
continuous improvement and and Berwick reviews and
including our people and our
acknowledges that our people are recommendations.
commissioners.
central to delivering our strategy.
Our approach aligns Berwick’s
We have therefore been careful to
We will use the implementation of improvement principles which are
develop goals and targets that are
the Quality Strategy to strengthen embodied within safe, effective,
measurable whilst trying to
confidence and pride in the services caring, responsive and well led
encapsulate our commitment to the
we provide. We want patients to be domain. The combination of
qualitative elements of our work.
confident that the Trust is among performance in each of the five
This will provide clarity for our
the best in the world. domains determines the overall
patients and external stakeholders,
quality of the healthcare we
and ensure that our people have
We want people working in and provide. We believe that we can
tangible, measurable and
with the Trust to be confident that improve services only by supporting
continuous improvement in all areas
hence our commitment to this
driver.
The previous quality account and
improvement programme for the
Trust focused on making immediate
quality improvements and ensuring
that we achieve a rating of ‘good’
in our CQC inspection, this strategy
and our priorities for 2018-19 and
beyond will strive to bring the trust
to an ‘outstanding’ rating.
6 London Ambulance Service NHS Trust
Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
The quality domains
The quality domains are outlined below, together with the descriptor of
what these mean. The domains match those used by the CQC to ensure we
are focused on making improvements which are aligned with our
regulatory body’s expectations.
Safe Caring
People are protected Staff involve and treat
from abuse and people with compassion,
avoidable harm kindness, dignity and
respect
Effective Responsive Well Led
People’s care, treatment Services are organised The leadership, management
and support achieves so that they meet and governance of the
good outcomes, promotes people’s needs organisation assures the
agood quality of life and delivery of high quality
is based on the best person-centred care,
available evidence supports learning and
innovation, and promotes
an open and fair culture
London Ambulance Service NHS Trust 7
Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019 Delivering the Strategy: How will the strategy be delivered and progress monitored? 8 London Ambulance Service NHS Trust
Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Quality Goals and Targets be incorporated into the quality
report and performance scorecards,
The strategy will be delivered ensuring they can be tracked from
through the achievement of our station to board. This will provide
quality goals, which are supported clarity on the Trust’s priorities and
by specific annual targets. These are will show the impact of the
outlined under each quality domain improvements we have made.
and have been chosen to ensure
that we focus on making Building Delivery Capacity
improvements where they are most and capability
needed, and on sustaining
improvements that have already Delivering the strategy will be
been achieved. We believe that if predicated on ensuring we have the
we can meet our goals and targets right skills and capacity across the
in these priority areas, we will see organisation. The outline plan
significantly improved outcomes for below sets out the key activities to
our patients and a better working achieve this aim, are detailed in our
environment for our staff. The goals implementation plan.
and targets under each domain will
1 Listen to staff and patients to determine priorities
2 Develop and tell our quality/QI narrative
3 Celebrate successes, showcasing existing work
4 Hold learning and awareness events
5 Visits to exemplar sites
Build will
6 Set up QI microsite (intranet and internet)
7 Develop a network of Quality Champions
Two key aims:
1 Have patient/carer involvement in all improvement work
1. To accelerate 2 Align service strategies, objectives, expectations and
delivery of the Create alignment reporting with improvement aims; also align key trust
highest quality, and deploy initiatives, e.g., Quality Account, Clinical Quality indicators,
best value care, infrastructure 3 Align individual goals/time with improvement aims (job
and best staff plans, appraisal, prof. development)
experience across 4 Develop informatics & analytics to support improvement
LAS by 2020
2. To embed
continuous 1 Initial assessment of current capability, gaps & priorities
improvement 2 Recruit core QI team & establish internal secondments
into daily Build 3 Find and train experts
operations at improvement 4 Build capability & capacity in different intensities &
LAS and to capability and formats
ensure best capacity a. Introductory training
support to b. In-depth longitudinal/applied training for teams
services across c. Develop coaches to support teams & initiatives
LAS 5 Executive and Board development
6 Embed in professional and leadership education
Through two main tracks – with rigorous measurement of
quality and efficiency/quality assurance framework
Apply, monitor 1 Major trust initiatives, incl: Patient and staff /volunteers
assure involvement programme; Strategy LAS Vision2020:
Strategic, service/pathway redesign
2 Local priorities: Each sector/station to work to a local QI
objective
London Ambulance Service NHS Trust 9Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Building the Will progress to deliver the required Evidence internationally (IHI)
Integral to all programmes must be improvements. Progress with these suggest for an organisation the size
the aim of robust patient and staff improvement projects will be of LAS that a commitment to
involvement so they support the reported via the Trust’s governance training at a minimum, 1-3% of the
development of what represents a and performance management workforce in improvement methods
high quality and efficient service. It structures. This will allow us to is required for continuous
is important that we continue to measure and monitor the improvement (Table 2 below) A
explore further ways of getting milestones, outcomes and programme to identify and
feedback from staff via Quality timeframes of the projects, with priorities the appropriate staff at all
Champions, patient and carers and clear lines of accountability and levels and utilisation of ‘train the
community groups, in addition to responsibility to the project owners. trainer’ techniques will build the
our continued engagement with Executive oversight of quality of capacity required. A small team of
the Patients Forum. The patient care in the Trust is through the staff trained in providing QI
involvement teams will develop a Quality Oversight Group, which will methodology and Human Factors
framework to ensure these aims report quarterly progress and approaches will provide the staff
and the successes they have already exception to the Quality Assurance with the skills and tools to empower
achieved are embedded. Committee. Trust board reporting them to lead their own QI projects.
will occur on a quarterly basis. Our QI improvement plans will be
The importance of ensuring that we annual Quality Account will report developed by staff at every level,
take every opportunity to engage on progress against the strategy with the focus to build capacity
with examplar sites partners in the and confirm the targets for the across, the workforce.
redesign of services and pathways in following year.
order to secure the right outcomes
is articulated in our organisational Building Capability to deliver
strategy. Supporting this the strategy
programme will be a We recognise that our staff are the
communication strategy that key to delivering the strategy and
includes intranet and internet we need to train and support
development. people to make continuous
improvement and improve systems
Creating alignment and processes. We have therefore
Alongside the quality goals and agreed to adopt a standardised
targets, we have developed approach to improvement Plan,
measurable and structured Do,Study, Act (NHSI QSIR model) to
improvement projects aligned to ensure staff have the tools they
our strategic and business need to sustain improvement. The
objectives. These projects have been capabilities needed to drive this
informed by analysis of a number of system of wide improvement and
measures of our performance which staff will be trained in
including: includes:
• Our strategic intent • An understanding of Human
Factors
• current performance against
national and local targets • Concept of safety systems
• our quality account • Driver diagram development
• areas of known risk • Improvement methodologies,
including Plan Do Study Act
• our CQC inspection and report (PDSA), Lean, Patient flow
during 2018 studies
• review of the key lines of • Change management principles
enquiry that the CQC publish.
• Measurement skills and
Each project has been assessed for knowledge
their potential to positively impact
on the Trusts strategic goals and • Flow and service re-design
targets and we are confident that management
we have the necessary work in
10 London Ambulance Service NHS TrustQuality Strategy : Vision 2020 and Annual Quality Account 2018-2019
QI capability model for LAS – by staff group and role
Table 2 QI Capability Model
Total Eventual
potential coverage Knowledge/skills needed What’s involved
needed needed
• Introduction to • Introductory e-learning
improvement & model for sessions (incl. at induction)
1. Front line staff improvement • Online/self-accessed
5,000 100%
• Identifying issues, • Over 3 year period
developing & testing ideas
• Measurement & variation
2. Clinical & • Deeper understanding of • Applied learning in teams over
operational improvement methods, time linked to opportunities in
leaders variation and measurement real work
400 100
• Goal-setting, leading and • Access to coaching
managing for improvement • Embedding into existing
5. Ex
programmes
3. Coaches* • As above, plus sophisticated • Applied learning and
perts
enabling and coaching skills reflection in coaching teams
Experts 10
for individuals and teams supported by classroom
programme
4. • Direction-setting, “mood” • Self-determined but typically
Exec & & leading for improvement includes: mix of
erts
Board • Link to strategy and overall individual/group; sessions with
250 250
priorities; appreciation of external experts; peer
5. Exp
systems; making variation visits/”Board-to-Station”;
and trends visible quality assurance visits”
• Deep Dive methodology • Careful objective-setting,
including of QI theory and review and planned (career)
science development
• Spread and implementation • Applied learning through
* Coaches drawn from wide variety
of professions and grades All Board • Coaching/mentoring, doing/coaching
n/a teaching • Reflection and peer support
members
• Knowledge-generation and • “Masterclasses”
research • Individually-tailored
• Measures for decision • Board Development Session
makers June
High Impact Innovations (DH 2012) reporting on our programmes and that is currently in place for the
requires NHS Trusts to prove to ensuring we respond to any North East sector.
commissioners that they are emerging risks will be achieved via
• Consideration of a Deep Dive
implementing technological and our quality assurance framework.
review
innovative solutions to improve The main response to the outcomes
quality. As a Trust we are already from these various reporting The streamlining of governance and
exploring the use of technology via mechanisms will be: ‘floor to Board’ assurance structures
the roll-out of hand held devices to will support the delivery of high
frontline staff, e-PCR development, • Immediate risk mitigation if quality and efficient care with early
tele-medicine/skype. Opportunities necessary) and review/update of identification of risks, monitoring
to explore technology further are risk registers performance issues quickly to
outlined in our IM&T strategy. ensure we continuously improve.
• Identification of a quality
The further development and
improvement activity: station,
Applying continuous assessment embedding of these frameworks
sector and trust wide using an
and improvement will continue through to 2018-2019
agreed criteria and methodology
Major trust initiatives, with rigorous and will support the development
measurement of quality and • Consideration of ‘intensive of a continuous improvement and
efficiency programmes and local support programme’ in areas learning culture.
sector and station QI objectives will that are not consistently meeting
be designed. Monitoring and standards – using the approach
London Ambulance Service NHS Trust 11Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019 Section 2: Looking Forward: Our Quality goals and targets 2018-19 Our goals are set out under each of the quality domains. The targets which support the delivery of these goals have been developed for our year one of the strategy. Each year we will review progress and ensure our targets are focused on areas where improvement is most needed and will be defined within our annual quality account. 12 London Ambulance Service NHS Trust
Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Safe Goal: To eliminate avoidable harm to
patients in our care as shown through
a reduction in number of incidents
causing severe and extreme harm.
extreme harm in year one and continue
to reduce the number throughout the
years of the strategy. Throughout year
one of our Quality Strategy, we will be
People are protected We believe harm is preventable not focusing on achieving sustainable
from abuse and inevitable. improvements in the target areas
avoidable harm outlined below; these targets aim to
We want to ensure our patients are as reduce avoidable harm in specific
safe as possible while under our care priority areas and set the trajectory to
and that they are protected from ensure that we can achieve our goal of
avoidable harm. Our goal will be to be eliminating avoidable harm by the end
below the national average for the of year three.
number of incidents causing severe and
Target 1 handed over to, and the ambulance
trolley cleared by, the receiving Handovers over the 15, 30
acute Trust within 15 minutes of and 60 minute target and
We will implement Health Assure arrival to enable the ambulances to total time lost, to reduce
reporting and Monitoring system to respond to the next 999 patient.
ensure that we have real-time quarter on quarter against
monitoring of our compliance Ambulance handover performance the same period in
against the CQC key lines of across London remained 2017/18
enquiry, clinical audits, NICE challenging throughout 2015/16
guidance, national alerts, at every and 2016/17; this continued into
level in the organisation. 2017/18 with patient’s frequently
experiencing handover delays in
Target 3
This system will provide assurance excess of 15 minutes following their
to the Board and our regulators and arrival at emergency departments During 2016-17 the Trust made
patients that we are meeting the (EDs). Between January and significant improvements in
high standards of care and safety September 2017, 62% of the medicines management in terms of
consistently across the whole patients conveyed by the London ensuring the tracking and
organisation. Scorecards will be Ambulance Service (LAS) to an ED monitoring of drugs at station level.
available from station to Board and experienced a delay, waiting The next phase is to ensure that we
will be used to monitor progress via beyond the target of fifteen have the most secure environments
our governance and assurance minutes for handover to on-going to store and monitor drug usage.
processes. We will be able to care. In the context of productive The second phase of the secure
identify areas for improvement ambulance cover hours beyond that drug room programme, that entails
more quickly and focus our effort in fifteen minute target, 49,494 hours re-designing the station
these areas. Our regulators will be were lost while delayed at an ED environment, fitting CCTV cameras
able see, assess and access evidence and this equates to 4,125 lost and more secure locking systems
with regard to our improvement twelve hour ambulance shifts in the will be rolled out across 2018-19. In
status at the ‘touch of a button’. same period. addition we have re-designed the
vehicle based bags that paramedics
It is recognised that hospital and other staff use when attending
90% implementation of handover delays is a multi-factorial patients. This provides the teams
Health Assure functionality system problem and we need to with more secure storage and an
by December 2018 work together to identify issues at ability to store all equipment that is
each stage and resolve them. The required on scene in one holdall.
LAS will continue to work with key
stakeholders from across London in
Target 2 an approach to assuring the safety 100% completion of
of ambulance handovers and secure drug rooms roll-out
Improving Hospital Handover Delays delivering improved performance across all sectors by March
National emergency care and a reduction in the average 2019 to agreed stations
performance metrics set a standard duration of ambulance handovers
for emergency patients arriving at across London during 2018-19.
hospital by ambulance to be
London Ambulance Service NHS Trust 13Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Target 4 identified that further work was
needed to understand the root
and manage and the equipment
will initially be remote form the
causes and ensure that learning to patient. The LAS has been accepted
During the latter half of 2016 it prevent recurrence was embedded on human factors train the trainer
became apparent that there were a across the Trust. programme supported by UCLH.
number of cases where During 2018-19, in conjunction with
defibrillation was being delayed It is clearly recognised that the all other aspects of risk reduction
during the management of cardiac challenges of managing a pre- and pathway development, we will
arrest. This trend continued into hospital cardiac arrest are very deliver training to relevant staff to
early 2017 and triggered a thematic different to in-hospital where the improve the management of these
analysis. Whilst it was believed that cardiac arrest team is made up of difficult scenarios with the aim of
the apparent increase in incidents different clinicians with per- reducing these incidents further.
might be related to the increased determined and specific roles and
number of defibrillator data who will have worked as a team
downloads by Advanced Paramedic together. The crew resource Increase the number of
Practitioners (APPs) coupled with a management challenges of pre- defibrillator downloads
significant drive to increase hospital cardiac arrest cannot be year-on-year to 20% by
reporting of potential incidents underestimated – the crews may
through the online incident end of 2019.
never have met each other, there
reporting system (Datix). It was will be public and family to support
14 London Ambulance Service NHS TrustQuality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Caring Goal: To provide our patients with the
best possible experience. Improving
the care we give to vulnerable groups.
We will aim to improve our position,
with our goal being to have patient
involvement in all service redesign
programmes and a patient involvement
Staff involve and treat We know that treating our patients framework developed to apply this
people with compassion, with compassion, kindness, dignity and goal consistently. The indicators
kindness, dignity and respect has a positive effect on outlined below will support this goal
respect recovery and clinical outcomes. To and help us determine whether our
improve their experience, we need to services are caring and patient centred
listen to our patients, their families and in all aspects.
carers, and respond to their feedback.
Target 1 Target 2 Target 3
Our work supporting patients with Our strategy to become London’s The LAS currently provides care to
mental health and in sometimes primary integrator of access to up to 9000 women a year at
complex medical conditions has urgent and emergency care on different stages in pregnancy, the
been acknowledged as exemplary. scene, on phone, on line, requires service covers 26 maternity units
As part of our Strategic Intent, we significant changes to the way in and three standalone birth centres.
are aiming to improve and develop which we deliver services to our
services that be recognised as patients. As part of this strategy is The services is recruiting the first
‘pioneering’ in relation to this the recognised need to widen and Practice Leads for Pre Hospital
patient group. Our aim is to ensure increase our patient involvement in Maternity Education across the LAS,
we have system wide collaboration both the development of these new and in the UK. They will form the
with all healthcare services to services and the monitoring of their Maternity team, alongside the
provide ‘seamless’, timely and the success. The Trust will therefore Consultant Midwife, to lead the
most appropriate care for these develop a Patient Involvement development of the Pan London
patients. Framework (PIF), with the support Maternity Pioneer Service.
of patients, public, specific patient
We will continue to work with key voluntary groups to ensure we have Maternity Pioneer Service:
stakeholders to provide the best genuine involvement and The pan London maternity model
possible outcome for these patients. participation and that the view of will aim to:
This work will include supporting these groups are considered in any
patients who frequently call the wide scale changes that we make. 1. a) Provide midwifery expertise
service during crisis or to request The new framework will also enable within the control room
help that is not necessarily provided us to capture feedback from a more environment allowing the ability
by the emergency services. We will diverse patient population through to reduce the number of
be increasing our resource internally the introduction of data collection ambulance conveyances (up to
to enable our expert staff to work methods, use of information 20% reduction)
closely with providers for example, technology, that will enable the
social services, to put key trust to directly compare how b) Provide a midwife advice line
interventions in place more rapidly different groups respond to and to provide a resource to staff
and consistently across the pan- identify specific issues and the both in the control room and on
London service provision. interventions to improve these. scene at a maternity episode of
care (increasing expert advice
capacity to 50% of calls fitting
Reduction in calls Evidence of patient criteria).
generated by those involvement in all QI and
patients classified as service re-design 2. Provide midwifery expertise
within a response vehicle alongside
frequent callers from April programmes.
ambulance clinicians to be
2018 baseline dispatched to imminent birth calls
Develop a commissioning model for
pre-hospital birth, when provided
by midwives within the emergency
services.
London Ambulance Service NHS Trust 15Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
The pan London model will pilot
the response model in a sector Reduce the number of
across London (aligned to the Local ambulance conveyance
Maternity System/STP footprint). (20%). Employ two whole
time equivalent practice
Alongside the Pioneer Model, a co-
designed and co-developed patient developments midwives
and staff engagement model will be and deliver a training
used to drive quality improvement programme 2018-19.
across the maternity care model.
16 London Ambulance Service NHS TrustQuality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Effective Goal: Ensure staff complaints in
providing ‘best practice’ care and to be
year-by-year basis.
in the top quartile for all national We aim to be in the top quartile for
People’s care, treatment clinical audit outcomes. outcomes for all those national clinical
audits in which we are eligible to
and support achieves Clinical audit is a key improvement tool participate and where data is analysed
good outcomes, promotes through which we continually monitor this way. This enables us to have
agood quality of life and and improve the quality of care that evidence that each of our services is
is based on the best we provide. By fully taking part in effective and promotes a good quality
available evidence national clinical audit programmes, we of life for our patients. Further
are able to benchmark our assurance of this will be provided by
performance against our peers, compliance and training that meets the
ensure the care we provide is evidence- changing nature of service delivery.
based and measure improvements on a
Target 1 Root and branch Target 3
independent training
We have chosen this target to We recognise that people are the
review completed.
ensure that we get the best clinical key to delivering our quality
outcomes for our patients. Implementation plan strategy. We therefore must make
Changing the way in which we developed by September sure that we are supporting and
deliver care and increasing the training our people to make
delivery of care using a multi-
2018 improvement continuously as well
disciplinary approach requires a as carrying out their roles. We want
fundamental review of the type and to implement new ways of working
quality of training that we proved Target 2 to improve our processes, systems
to our staff. In addition it is and services with transparent
important that we ensure staff have measurement and track progress.
During 2017-18 the LAS, as with all
the time to attend training, a We have therefore decided to
other ambulance services,
constant pressure with the adopt a standardised approach to
implemented the Ambulance
increasing demand on delivering quality improvement to make this
Response Pilot (ARP). The new
the service we provide. We will possible. The NHSI methodology is
response targets set out different
carry out a root and branch review designed to support and encourage
response categories and set out an
during the early part of 2018 to our staff by providing them with
approach that requires Trusts to
inform an improvement programme the tools they need to make
report on new quality indicators.
to ensure that : systems and sustained improvements. We want
During 2018-19 the LAS will work
processes are robust with strong this to stimulate a culture of
with the business intelligence team
governance frameworks; the learning and development in
to ensure that we develop methods
training is appropriate and easily improvement and ensure that
to collate and report on these new
accessible; a revised training change becomes the way of doing
indicators. In doing so we will have
programme to include any further things in the Trust. As part of this
clear evidence of areas were we
training requirements highlighted process, the Trust has gained
have improved patient outcomes
to meet the changing nature of financial support during 2017-18 to
and also have the ability to
delivery, the programmes of increase the capability in relation to
highlight areas were we may not be
training align to operational both Quality Improvement and
meeting the standards of care that
delivery, and to ensure that staff are Human Factors training
we strive to deliver.
released to attend training and programmes. We will set out an
meet statutory requirements. We implementation plan that enables a
will also identify potential income New quality Indicators critical mass of staff to be trained
generation, potential opportunities and also ensure this is aligned to
and have an identified ‘training
developed and being our quality assurance processes to
brand’. Ultimately the aim is to reported via performance provide continual feedback,
ensure our staff continue to provide scorecards by December reporting and learning (see outline
clinically effective care based on 2018 plan in section 1).
best practice guidance.
London Ambulance Service NHS Trust 17Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019 QI training plan agreed and 100% of identified key cohorts trained by September 2018 Target 4 The changing nature of our operating model, requires us to review the way in which our staff are allocated to their shifts. The Director of Operations will continue to work with colleagues to roll out this significant piece of work supported by our new Forecasting & Planning Team. A Trust-wide review of rosters will be completed by March 2018 with implementation due in summer 2018. At least 2 Sector roster reviews completed by September 2018 and remaining sectors by April 2019 18 London Ambulance Service NHS Trust
Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Responsive Goal: To consistently meet all relevant
national performance targets
have shown that our patients agree.
standards through responsive patient To do this, we will continue to review
pathways in year one, and exceed our processes to ensure they are as
Services are organised them by year three. efficient as possible, while keeping the
so that they meet needs of our patients central.
Having responsive services that are
people’s needs organised to meet people’s needs is a As well as the national targets above,
key factor in improving patient we will focus on the following targets
experience and in preventing delays to to improve our responsiveness as a
treatment, which can cause harm to Trust to patients who complain.
our patients. Our engagement events
Target 1 in dealing with complaints from the
patients and public we serve. We
continue with our patient and staff
stories at the Board, which have
will undertake a review of our been instrumental in making sure
Over the last 12 months the Trust complaints responses, supported by the executive team understand
has consistently been one of the our patients, to ensure that our better the experiences of our
strongest performing ambulance complaints responses include the patients and staff.
services. It is currently the third appropriate information and
highest national performer in express our apologies in a genuine
implementing the new ARP way. We will aim to further improve Over 75% of complaints
standards. the turnaround time for our letters letter being responded to
and include more information in within the 35 day timescale
Additional recurrent funding has relation to the lessons we have
been secured over the last six learned. In addition we will
months for additional frontline and
Emergency Control Services staff,
and we have also introduced an
additional Incident Response Team
to further strengthen our resilience
capability.
We will review our
operational model by
quarter three and work
towards delivering the
revised standards as set
out in ARP.
Target 2
The Patient Experience Team is
working with the sector teams to
provide feedback and actions to
enable learning from complaints.
We continue to respond within
timelines for complaints, meeting
the majority of patient response
within 35 days.
Throughout 2018-19 we will focus
on improving further our processes
London Ambulance Service NHS Trust 19Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Well Led Goal: To increase the percentage of our
people who have been trained and
patients. Our goal is to increase the
percentage of people who would
provided with leadership recommend our Trust as a place of
The leadership, management development. work. By supporting our people to
develop, we are improving the culture
and governance of the Evidence shows that people who are and ethos of the Trust – both as a
organisation assures the engaged and happy in their jobs, place to work, and as a patient. This
delivery of high quality respected and given opportunities to goal will be supported by the targets
person-centred care, learn provide better care for their outlined below.
supports learning and
innovation, and promotes
an open and fair culture
Well led mandatory requirements which
have a direct impact on patient
Will continue to implement the
P&OD strategy through 2018-19 and
During 2017-18 we have safety. progress the addition of activity
strengthened our leadership team, outlined below:
our governance systems and
85% compliance with • Implement our Trust strategy
processes and set out key strategies
e.g. People and Organisational statutory and Mandatory and refresh supporting
Development, IM&T, which will act training 2018-19 strategies. Working with STPs in
as key enablers going forward to developing and implementing
the delivery of our strategic system-wide improvements .
objectives. • Complete re-structures.
Target 2 • Develop and implement staff
Target 1 Fully implement our leadership
communications and
engagement model.
development programmes at all • Continue to strengthen Risk
Our statutory and mandatory levels and develop a culture of Management systems and
training programmes ensure the professionalism, with all staff clear processes.
safety and well being of staff and about their roles and
patients. During 2017-18 we moved • Continued implementation of
responsibilities.
the majority of our training to on- the Quality Improvement Plan
line e-learning and also and Quality Improvement
implemented a new reporting tool Leadership programme capability across the
on ESR to improve the ability to organisation.
developed and
monitor and report compliance. • Maintain the focus on culture
implementation plan in
We have chosen a target of 85% and holding people to account.
compliance to demonstrate that our place
• Developing a culture of
staff comply with statutory and professionalism, with all staff
clear about their roles and
Equality and Diversity responsibilities.
• Complete re-negotiation in
At LAS we are committed to promoting equality of opportunity and terms and conditions of annual
diversity to enhance our inclusion work. LAS has committed to ensure leave and flexible working.
that equality, diversity and human rights are embedded in all areas of • Continue to strengthen IM&T
our employment, planning and service delivery. We strive to provide resilience.
excellence in all we do and recognise the value that Inclusion brings. We
are committed to ensuring that all our employees are treated with • Continue to develop and
dignity and respect and given equal opportunity and encouragement to implement WRES improvement
progress and develop within the organisation. programme
• Continue to develop and
We strongly believe that diversity and inclusivity in all its forms delivers
implement Equality and Diversity
greater impact in the work we do and enhances the services we deliver
Action Plans
to Londoners. Our commitment to the principles of Diversity and
Inclusion informs all of our work with our people.
20 London Ambulance Service NHS TrustQuality Strategy : Vision 2020 and Annual Quality Account 2018-2019 Section 3: Looking Back: Quality performance 2017-18 The progress against our targets and goals we set out in our Quality Account 2017-18 are outlined here, under the quality domain headings. London Ambulance Service NHS Trust 21
Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Quality Priorities 2017-18 Target 1: Development of Target 2: Improve and
The priorities for 2017-18 as set out pathways for patients embed learning from
in our previous Quality Account
(2016) are highlighted below who fall, have mental incidents
against the 3 domains for quality, health issues, are at the
Patient Safety, Experience and A learning and quality improvement
Effective care. Progress against each
end of life and bariatric. framework was agreed by the
of the domains is provided, where Board in November 2017 and is now
relevant impact key performance Our strategic intent document, being implemented, supported by a
indicators are included developed during 2017-18 , sets out communication strategy.
the further system wide pioneering Implementation will be complete by
services we aim to develop and March 2018 and continuous
Patient Safety deliver during 2018-19 and embedding of the framework will
onwards. This year work has continue, supported by the revised
During 2017-18 we introduced and progressed in relation to mental quality assurance framework. In
established a new integrated health support, with increased addition monies to train a cohort of
Quality & Assurance directorate training, alternative care pathway staff in quality improvement
which aligns quality functions into development, data sharing methodology and human factors
one directorate. Recruitment to alongside the recruitment of an was also provided by NHSI. This
new posts has now concluded and additional 3 mental health programme of work will start in
the structure brings both an professionals to provide advice in July 2018 and continue throughout
increase in capacity and capability the clinical hub and support the 2018.
to the quality agenda across the initiation a mental health response
trust. Quality governance car. This is a pilot to enable mental We have evidence of learning from
frameworks have been reviewed health clinicians to work alongside incidents from the inclusion of
and rationalised with clear lines of paramedics to respond to patients feedback in core skills refresher
reporting via new Terms of undergoing a mental health crisis, courses, various changes to working
Reference, minutes and key issue and commenced in December 2017. practices, i.e. ventricular fibrillation,
reports to provide assurance and This will be evaluated and, if managing patients with spinal
allow escalation of issues from successful, rolled out to other injuries. During 2017-18 we had an
‘floor to Board’. A risk management sectors. independent review by our internal
improvement programme has also auditors (KPMG) who gave the Trust
been developed and continues to In addition the Trust has been Significant Assurance rating with
be implemented to identify key successful in gaining funding for regard to the serious incident
safety and quality risks more three full time staff to provide investigation and learning process.
accurately and to ensure staff are dedicated support to End of Life
trained in identifying risks and care providing advice and training In addition our no/low harm
regularly review and assess risks to for staff in giving support to reporting rates have improved to a
patient safety and quality of care. families and patients at end of life. currently in the higher quartile
In addition clinical audit, alternative compared to national benchmarked
care pathway utilisation and service levels during 2017-18. LAS are now
development will also be part of reporting over 90% of incidents
this remit. within the no/low harm category
(see charts opposite).
A Bariatric equipment business case
is being presented to ELT at the end
of February 2018, this outlines a
significant investment, this will
need to align to the current logistics
work programmes and consider the
impact of the ARP future operating
models. In addition considering the
type of equipment and support we
require to ensure these patients
have effective and dignified care.
22 London Ambulance Service NHS TrustQuality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Learning from experience management of paediatric 10 Incorporation of case studies to
Below show some examples of patients with particular focus on the internal leaning from
where the Trust have made the measurement of oxygen incidents Insight magazine
improvements as a result of serious saturations
11 Changes to practice included in
incident investigations: 6 Development of a feedback core skills refresher courses for
1 Change in practice regarding mechanism of all maternity both EOC and frontline
the management of cardiac related incidents to the operations
arrests as a result of a significant maternity training programme
12 Case studies included in the
number cases concerning 7 Process for investigating and internal Clinical Update
delayed defibrillation managing thematic reviews of magazine
2 Changes within the Gazetteer similar incidents. For example;
system to improve the accuracy delayed defibrillation and the
of locations across London Non-emergency Transport
Service
3 Policies that have been
identified to be unfit for 8 Equipment concerns highlighted
purpose have been reviewed to the equipment replacement
and updated programme which assisted in
the development of business
4 Improved training, compliance cases to replace specific pieces
audits and the development of a of equipment
new policy for the management
of breached Patient Group 9 Learning from incidents training
Directions delivered to all EOC staff and
included on the paramedic
5 Guidance issued to staff on the academy courses
London Ambulance Service NHS Trust 23Quality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Patient Experience against their monthly performance considerable reductions utilising a
on hand hygiene. Infection control multi-agency approach to case
practices at A&E have also management to our highest volume
Target 1: Effective and improved, vehicle cleaning remains callers. However we are reviewing
consistent risk assessment an area of focus as does hygiene the resources required to support
completed for patients standards in some identified the delivery of a programme to
presenting with a mental stations. These are being closely increase the potential of reducing
health crisis monitored through regular quality the significant impact this patient
Revision to the risk assessment tool assurance visits. We will utilise more group have on demand in 2018-19.
and training have been introduced fully the Perfect Ward app to allow The aim will be to enable case
during the year, we have seen an digital uploads of data from station management to be undertaken for
improvement in the quality of visits during 2018-19 a larger number of cases through
mental health assessments, with a increasing capacity within the
current average of 91% of core Target 3: Ensure patients have current dedicated frequent caller
criteria being recorded as timely and appropriate access team, allowing increased
demonstrated through the involvement in system wide
to services initiatives, evaluation of
monitoring of monthly clinical
performance indicators. In addition interventions on patient outcomes,
System wide demand management patient experience, operational and
bespoke training has been delivered projects to improve care and
by our mental health nurses to staff system wide performance.
experience of patients have seen
within our emergency operation improved response times, with the
centres, call handling staff and Trust-wide performance:
Trust meeting the majority of Consistently meets response targets
clinicians; to specialist response targets consistently.
teams such as the joint response under the new operational model
unit; to specific cohorts of staff such as outlined on page 38, Table 12.
Work undertaken with specific
as incident response officers and frequent callers has shown
clinical team leaders (with over 200
staff trained in specific areas such as
mental capacity). We anticipate the
introduction of mobile devices will
further improve our ability to carry
out and record assessments real-
time with guidance immediately
available from various ‘apps’ that
staff can access quickly on-scene.
Target 2: Improved
compliance with Infection
Control standards
Infection control issues identified
internally and through CQC, have
improved significantly, we are
seeing the majority of sectors
showing over 90% compliance
Table 3
Apr May Jun Jul Aug Sep Oct Nov Dec Jan Feb
Trust Overall 97.0% 97.0% 94.8% 94.3% 96.8% 95.7% 93.0% 95.0% 95.0% 93.0% 91.0%
North East 95.0% 95.0% 97.8% 96.2% 96.0% 97.0% 98.0% 98.0% 98.0% 98.0% 97.0%
North Central 99.0% 99.0% 82.5% 91.2% 97.0% 97.0% 97.0% 90.0% 97.0% 91.0% 97.0%
North West 99.0% 99.0% 98.3% 98.0% 98.0% 96.0% 96.0% 93.0% 96.0% 98.0% 98.0%
South East 99.0% 98.0% 98.3% 95.5% 97.0% 98.0% 99.0% 97.0% 95.0% 95.0% 99.0%
South West 97.0% 97.0% 94.0% 94.0% 96.0% 98.0% 99.0% 97.0% 95.0% 95.0% 96.0%
Others 95.0% 95.0% 100.0% 91.0%
HART 65.0% 81.0% 89.0% 80.0% 65.0%
NETS 93.0% 93.0% 9.3% 91.0% 88.3% 96.0% 95.0% 83.0% 87.0% 85.0%
24 London Ambulance Service NHS TrustQuality Strategy : Vision 2020 and Annual Quality Account 2018-2019
Clinical Effectiveness ED Site visits up to October 2017 Cohorting process
The Emergency Care Improvement Patient cohorting is a process
Target 1: Improve outcome as Programme (ECIP) were tasked to whereby ambulance clinicians
reported Ambulance Quality complete a series of site visits and handover the care of their patient
Indicators assessments leading to to an ED clinician immediately after
improvement recommendations at triage regardless of bed availability.
We have implemented and various acute hospitals. Follow up This can allow ambulances to
constantly measure best practice visits commenced in October/ become available for dispatch to
models of care following the November to measure progress another incident more quickly; it is
introduction of the Ambulance against the individual the responsibility of Acute Trusts to
Response Programme (ARP) in recommendations made by ECIP. implement and staff this.
October 2017. Currently we are 3rd This work has also included Ambulance-led cohorting is the
best performing ambulance trust widespread sharing of Patient Flow same process, but is implemented
nationally against these response guidance with operational leads at and staffed by the LAS because it is
time indicators. each acute site and the felt that the risk of not doing so
identification of LAS contacts for would be to the significant
We have maintained our programme trusts. detriment of the Trust and patient
against the Stroke Care bundles at safety. A standard process for
96%. However, in relation to STEMI LAS engagement managers have Cohorting across London including
patients we are below the national worked with their local EDs to the triggers and reporting process
average. We will continue to focus support ECIP led initiatives designed for when it can be used has been
on this. at reducing the potential for designed and implemented with the
handover delays to occur. By agreement of NHS E.
Target 2: Standardise hospital identifying patients who could
handovers including the use either wait or be seen in a hospital NEWS is based on a simple scoring
chair (#fit2sit). Or through system which allocates a score to
of NEWs for the sickest reviewing the conveyance choices physiological measurements in adult
patients made by LAS clinicians (Front Door patients. The aggregate NEWS score
Challenge); for example could their provides an indication of how
We recognised that hospital patient of been seen in another unwell the patient is. Patients are
handover delays is a multi-factorial area of the department, or have assessed and attributed a score and
system problem and we needed to been conveyed/referred to an category (Red ≥7, Amber 5-6 and
work together to identify issues at alternative pathway. GreenYou can also read
